Newborn Screening Specimen Card Tips
A
Please remove the top sheet of the newborn screening card before sending it to MDH.
Last Name: Record the
infant’s last name as it will
appear on the birth certificate
Do not assume the infant’s
last name is the same as the
mother’s last name.
Multiple Births: If the infant is one of a set of twins,
triplets, etc., check “Yes” and check the number that
corresponds to the infant’s birth order. For example, for the
first baby born in a set of twins, check “ es” and “1.” For
the second baby born in a set of twins, check “Yes” and “2.”
Birth Date/Time and Date/
Time of Collection: Please
record the date/time of birth
and the date/time of blood
spot collection in military
time. Testing cannot be
performed without accurate
dates and times.
Birth Weight: The weight of the infant at
birth (not weight at screening) is important for
screening test accuracy. If the infant weighed
under 2000 grams at birth, please use a
yellow screening card. Always write the birth
weight in grams.
Follow-up Physician:
Accurate contact information
for the physician who will
care for the child after
discharge is extremely
important. This is who our
staff will contact in the case of
an abnormal screening result.
If the physician is not known at
the time of screening, please
enter the name of the clinic
where the infant will be seen.
Newborn Screening Program
Risk Factors: Check all risk factors that apply. If any boxes are
checked, please use the extra space in the “Risk Factors” box or
in the notes section at the bottom of this form to elaborate (e.g.,
specific birth defect, the name of the disorder in family histor ,
etc.). In the case of a deceased sibling, please record the cause
of death in the space provided.
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601 Robert Street N., Saint Paul, MN 55155
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Submitter Information: To avoid
delays in reporting results, be sure
to write in all submitter information
including the name of the facility or
midwife collecting the specimen and
submitter number. This is needed
in the event that a new specimen is
needed and to send reports back to
the submitting hospitals and clinics.
Phone: (800) 664-7772 or (651) 201-5466
ID#: 54252
REV: 02/2015